Prior Authorization Form Psoriasis Agents
ADVERTISEMENT
1Today’s date _____________________
Date medication needed ___________
Prior Authorization Form
Psoriasis Agents
ONLY COMPLETED REQUESTS WILL BE REVIEWED
®
Stelara
Check one:
New start
Continued treatment
Physician information (please print)
Patient information (please print)
Patient name __________________________
Prescribing Physician ________________________________
Office Address _____________________________________
Address ______________________________
City, State, ZIP _____________________________________
City, state, ZIP _________________________
Office Contact ______________________________________
Patient telephone # _____________________
Office Telephone # __________________________________
Patient ID # ____________________________
Date of birth ______Height _______ Weight _______
Fax # ____________________ NPI ____________________
Upon approval, delivery is available by completing the section below.
N/A – No delivery requested, authorization only - physician will use office supply
Delivery requested (indicate where medication should be delivered: Physician’s office Patient’s home)
**A copy of the prescription must accompany the medication request for delivery.**
1.
Physician specialty (required; specify all):
Dermatology
Other _________________________________
2.
Diagnosis for drug requested (must include ICD-9):
696.1 Chronic plaque psoriasis
Other (specify diagnosis and ICD-9) ______________________________
3.
Patient medical information:
Yes
No
a. Is chronic plaque psoriasis moderate-to-severe?
b. Has the patient been evaluated (i.e., tuberculin test)?
Yes
No
c. Does the patient have a current infection?
Yes
No
4. Patient history (please list any previous or current therapies related to the diagnosis):
Drug Name
Date(s)
Duration
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Please add any other supporting medical information that may be useful in the decision-making process:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
5. Prescription information:
Quantity _______________ Refill x _______month(s)
Instructions (include dose) _______________________________ every _________ day(s)/ week(s)/ month(s)
Physician’s signature _________________________________________________________________________________
Fax completed form to 215-761-9165. Your office will receive a response by fax within two business days.
4/2013 INJ-08.00.82b
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company,
and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business